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NavMed P-369 




ff&&g&s 



Vol. 44 



Friday, 24 July 1964 



No. 2 



TABLE OF CONTENTS 



FEATURE ARTICLE: Drugs Are Double-Edged Swords 3 



MEDICAL ABSTRACTS 



DENTAL SECTION 



Testicular Tumors 12 

Surgical Operations on the Un- 
born Fetus May Presage New 
Era for Immunology Research . .14 

FROM THE NOTE BOOK 

A New Correspondence Course 

in Medical Department 

Orientation 15 

Naval Medical Research Reports . .16 

MISCELLANY 

Joint Armed Forces Procedures 
for Examination of Candidate s 
for Service Academies. ...... .17 

Federal Hospital Luncheon - An 

Announcement 19 

It Can Happen Here - a timely 
public health item by Con- 
gressman Hall of Missouri . . . .20 



The Hazards of Dental Radiation . . 22 

Effects of Complete Dentures 

on Facial Esthetics 24 

Hemangiomas of the Mandible 

and Maxilla 25 

Numbness in Chin May Point 

to Carcinoma 25 

The Problem of Broken Appoint- 
ments 26 

Professional Notes 27 

OCCUPATIONAL MEDICINE 

Effects of Mild Carbon Monoxide 

Intoxication 28 

RESERVE SECTION 

Some Plain Talk for Junior 
Officers - Commentary by 
the Executive Director of the 
Naval Reserve Association. ... 38 



United States Navy 
MEDICAL NEWS LETTER 



Vol, 44 Friday, 24 July 1964 No. 2 

Rear Admiral Edward C. Kenney MC USN 
Surgeon General 
Rear Admiral R. B. Brown MC USN 
Deputy Surgeon General 

Captain M. W. Arnold MC USN (Ret), Editor 

Contributing Editors 

Aviation Medicine Captain C. E. Wilbur MC USN 

Dental Section Captain C. A. Ostrom DC USN 

Occupational Medicine jCDR N. E. Rosenwinkel MC USN 

Preventive Medicine Captain J. W. Millar MC USN 

Radiation Medicine JZDB. J. H. Schulte MC USN 

Reserve Section, .Captain K. W. Schenck MC USNR 

Submarine Medicine .CDR J. H. Schulte MC USN 



Policy 

The U.S. Navy Medical News Letter is basically an official Medical Depart- 
ment publication inviting the attention of officers of the Medical Department 
of the Regular Navy and Naval Reserve to timely up-to-date items of official 
and professional interest relative to medicine, dentistry, and allied sciences. 
The amount of information used is only that necessary to inform adequately 
officers of the Medical Department of the existence and source of such infor- 
mation. The items used are neither intended to be, nor are they, susceptible 
to use by any officer as a substitute for any item or article in its original 
form. All readers of the News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Change of Address 

Please forward changes of address for the News Letter to: Commanding Offi- 
cer, U. S. Naval Medical School, National Naval Medical Center, Bethesda, 
Maryland 20014, giving full name, rank, corps, and old and new addresses. 



The issuance of this publication approved by the Secretary of the Navy on 
4 May 1964. 



U.S. Navy Medical News Letter, Vol. 44, No. 2 3 

FEATURE ARTICLE 

Drugs Are Double -Edged Swords* 

By Dale G. F. Friend MD. Journal of the American Pharmaceutical Assn. , 
NS4(5): 221-225, May 1964. Permission for republication from this origi- 
nal source of the article has been granted by Dr. Friend and by the Editor 
of the Journal of the APA - Mr. George B. Griffenhagen. 

When I graduated in 1935 from medical school, we had very few specific and 
highly potent remedies available. Then came the sulfas, penicillin and a whole 
flood of antibiotics. Through the enthusiasm generated by these agents in the 
field of medicinal chemistry literally hundreds of agents have come. These 
are not weak drugs; these are agents that have great potency. They have great 
possibilities of doing goodandthey have equal possibilities of doing harm. We 
have actually been propelled into this situation and many of us who were grad- 
uated even 15 years ago have been slow to recognize how serious this impact 
has been in medical practice. I am surprised at times that any physician can 
practice sensible medicine with the great number of agents that he has avail- 
able and the tremendous amount of information he must get together to handle 
these agents wisely. 

Information now being gathered at Peter Bent Brigham Hospital will 
provide background for the difficulties in today's practice of medicine. For 
every patient discharged from the hospital a record on drug reactions is filled 
out giving the following information -What drug was used? Did the patient have 
a reaction? What type of reaction did he have? What happened to the patient? 

We have collected data for about nine months and are finding that over 
two percent of all patients who are discharged from the hospital have drug re- 
actions. Some of these are minor and some are very serious. 

Is this a new problem? We used to have iatrogenic disease created by 
physicians for things that they did to their patients. Up until about the turn of 
the century most of these iatrogenic diseases came about through surgery. 
Something went wrong with the patient-he lost a limb or an eye or had some 
serious complication. But since that time, and now, without any doubt, the 
greatest number of iatrogenic-created problems are coming from our drug 
therapy. The two percent reactions do not represent by any means the total 
number of people who are getting drug reactions. As we encourage our house 
officers and physicians to report every type of drug reaction, these figures 
will go much higher. 

Iatrogenic disease has a parallel in so-called civilian habits. Students 
of philosophy know that Pythagoras was not only a mathematician but also a 
Greek philosopher. He set down a series of rules and regulations for his fol- 
lowers. Among these rules was a restriction on eating beans. Philosophers 
down through the centuries have laughed at this, pointing it out as one of the 

* Adapted from a paper presented at the Federal Services Seminar, Nov. 7, 
1963, in Washington, D. C. 



4 U. S. Navy Medical News Letter, Vol, 44, No. 2 

peculiarities of Pythagoras. But actually, he was wise. There are certain 
beans thatcancause severe sensitivity with destruction and hemolysis of blood 
which can be very dangerous and even result in death. Very recently we have 
found a drug used in the treatment of malaria called primaquine which in cer- 
tain people destroys blood. It causes hemolysis and jaundice and can cost a 
personhis life. Many people of Mediterranean origin and many Negro soldiers 
were exposed to this drug and were inflicted with jaundice. These patients, we 
finally found, had a defect in their red blood cells in which a certain enzyme 
was lacking. When these individuals are given this drug and also this particu- 
lar bean, they will develop a severe reaction. So actually, Pythagoras knew 
his beans. 

In ancient times a very famous king of Babylon named Hammurabi 
really took the first action against iatrogenic disease. He was very much con- 
cerned about physicians' fees and what to do in case the physicians had unto- 
ward results. The Code of Hammurabi states that if a doctor causes loss of 
life or limb in the case of a gentleman, he shall have his hands cut off. In the 
case of a slave, he will render equal value- slave for slave. This is a pretty 
serious approach to the problem of compensation for iatrogenic disease. Our 
approach now is to make physicians and pharmacists pay for untoward reac- 
tions that occur in patients. 

For example, when a physician prescribes a drug for a patient, he 
is carrying out an experimental procedure. No matter how the drug may have 
been used or how many times it has been prescribed or to how many thousands 
of people it has been given, there is a possibility at any time of untoward re- 
actions occurring. 

In 1956, the Council on Drugs of the American Medical Association set 
up a program to check on blood dyscrasias created by drugs. It asked for in- 
formation on various types of damages that occurred to the hematopoietic 
system. Investigators found that about 31 percent of the people who get drug 
reactions of the hematopoietic system have aplastic anemia and 38 percent 
have agranulocytosis. 

There are now established adverse drug reaction committees in vari- 
ous hospitals who report diseases that are created by drugs but there is still 
much to be done. Hospital pharmacists are also engaged in this activity of 
collecting material to report on adverse drug effects. The AMA Council on 
Drugs has established a nationwide reporting system and the Food and Drug 
Administration has set up a similar system. Sooner or later these groups 
must get together, pool all their data and try to come out with some unified 
report in which we can get a more accurate idea of exactly what is going on 
in this field. 

Not many years ago, Robert Moser published a very important article 
in which he pointed out some 40 new diseases created by medical progress. 
Most of these were diseases resulting from the effect or adverse effect of 
drugs. They are new diseases that have been created by drugs themselves. 
Time and again the skilled physician who deals with drug effects has to step 



U. S. Navy Medical News Letter, Vol. 44, No. 2 5 

in and stop the use of a drug to prevent a patient from developing some seri- 
ous complication. The diagnosis of drug complications is getting to be a very 
important field of medical science. Let us look into some of the mechanisms 
behind these so-called iatrogenic diseases resulting from drug therapy and 
learn what things are likely to happen. 

Everybody should know the dosage of the drug he is going to use and 
should follow instructions explicitly. Unfortunately, in the case of many of our 
newer drugs, the exact dose varies with individuals. If physicians are to get 
maximum benefits from any agent in any individual patient at the particular 
time of his illness, he must titrate the dose to the patient's needs. For exam- 
ple, a patient on full digitalization who receives a diuretic could be in danger 
of potassium depletion. 

Patients who have ulcers or irritated stomachs are given agents which 
increase irritation or activate ulcers. Often I have to tell a house officer — 
"Don't give large doses of reserpine. All you are doing is increasing the se- 
cretion of hydrochloric acid. You may activate or create an ulcer. Be careful. 
Adjust the dose carefully. Don't create an ulcer all in the course of treating 
mild hypertension. " 

We give excessive doses of some of our drugs. We often give huge 
amounts of iron and enormous amounts of iodides. Neither one of these is 
needed in such large doses by the great majority of patients. We can give iron 
inmuch smaller doses, take a little longer for the anemia to be overcome and 
not have a person develop severe irritation of the gastro-intestinal tract. The 
more of these foreign molecules which are put in the human organism, the 
greater is the possibility of getting some kind of reaction. 

Some of our new drugs confuse physicians. For example, I was called 
in to see a patient in emergency who was in coma and nearly dead. What had 
happened? The dose of tolbutamide said 3. grams the first day, 2. grams 
the next, etc. Here was an elderly lady of 75 with a very slight elevation of 
sugar who suddenly received 3. grams of tolbutamide and went into hypogly- 
cemia. She was nearly dead before the trouble was discovered and she was 
brought out of her coma. Deaths have occurred from this reaction. 

We must pay more attention to pharmacological aspects other than the 
principal effects that we are seeking. Very few drugs have one specific action. 
Most drugs have several. Some are almost as prominent as the major effect. 
We must know these other reactions of drugs because they may have serious 
implications as far as patients are concerned. 

As an example, atropine is used to relieve a bowel spasm but it can 
throw a patient into severe glaucoma or paralyze his bladder so he can't uri- 
nate, particularly if he is an elderly gentleman with chronic prostatitis. Uri- 
nary retention in turn can lead to very serious problems with catheterization 
and infection which may cost the patient his life. If he is given enough atropine, 
his bowel may suddenly go into complete paralysis and he will develop obsti- 
pation. 

For many agents these other effects are known -for example, morphine 
causes nausea and vomiting and itching of the skin. Patients also lose their 



6 U.S. Navy Medical News Letter, Vol. 44, No. 2 

vasomotor reflexes. If they stand up, their blood pressure falls and they may 
faint. 

Other factors to consider are absorption, duration of action and elimi- 
nation of the drug. Many of our iatrogenic diseases come from a lack of prop- 
er information on these aspects. For example, if under normal circumstances 
only five percent of a highly potent drug is absorbed in the gastrointestinal 
tract, there is a possibility under different conditions that seven or eight per- 
cent will be absorbed. If so, an ideal situation exists for a toxic reaction. If 
five percent gives a good clean clinical response and suddenly the absorption 
is increased to eight percent, a severe toxic effect may occur. Many drugs 
have come on the market which are highly potent but have limited absorption 
and may create toxic symptoms if the absorption becomes a little too high. We 
must always look with a certain amount of suspicion on a highly potent drug 
that is absorbed to a very small extent because this opens the pathway to pos- 
sible serious toxic effects. 

One must know something about the metabolism of a drug. How long 
does it stay in the body? Is it removed by the kidneys? For example, if a drug 
is removed a hundred percent by the kidney and takes quite a time to be elimi- 
nated, a great deal of care should be used in giving it to an elderly patient with 
poor renal reserve. A young man of 25 with one hundred percent kidney func- 
tion has a tremendous kidney reserve and can handle emergencies very easily. 
But a man of 75 doesn't have this reserve. He has lost it as the years have 
gone by and although his kidneys may be functioning normally enough and 
holding him, if he is suddenly subjected to an extra strain, he can go into a 
toxic state because he does not have enough reserve. 

I was called in to see a patient with a skin rash. He was receiving a 
penicillin and streptomycin mixture -it was believed the patient had a penicillin 
reaction and the staff wanted me to see if there was anything that could help. 
Here was an old gentleman, who had albumin in his urine, stretched flat on 
his back with a broken leg getting enormous doses of penicillin and streptomy- 
cin. It is true that he had a skin reaction. But when I held my finger in front 
of his eyes they were dancing with nystagmus. He obviously had impaired 
renal excretion already and he had lost his reserve as the years went by. He 
couldn't eliminate the streptomycin as rapidly as he was receiving it and he 
was already getting a vestibular reaction. They could have healed his leg and 
cured his infection, but he would never have walked again because his vestib- 
ular function would have been gone. 

Another principle is interference with metabolic processess. For ex- 
ample, mineral oil washes out vitamin A, D, and K from the bowel. But how 
many physicians and how many pharmacists would caution a patient getting 
anticoagulant therapy? If too much vitamin K is lost, a severe hemorrhage 
may cost the patient his life. A. little thought can prevent such interference 
with metabolism of the body. 

Important elements of the body are often tied up with the metabolism 
of certain drugs. Several years ago some patients who received isoniazid for 



U.S. Navy Medical News Letter, Vol. 44, No. 2 7 

the treatment of tuberculosis developed peripheral neuritis. This neuritis was 
of such a severe degree as to incapacitate the patient completely and lead to 
paralysis and extremely severe pain of the peripheral nerves. It was found 
that a metabolite of isoniazid tied up with pyridoxine. The removal of pyri- 
doxine, an essential vitamin, will lead to neuritis. We now give pyridoxine 
along with isoniazid and there is no neuritis. 

Macrocytic anemia occurs in some people who receive large doses of 
diphenylhydantoin for long periods of time. This is an example of interference 
with folic acid metabolism and macrocytic anemia can occur. Itis an unusual 
type of anemia and, until it was worked out and recognized as such, it was a 
real puzzle. We all know that physostigmine and neostigmine enhance the 
parasympathetic nervous system and cause diarrhea, flushing, extremely 
slow heart rate and in many patients collapse or even convulsions. 

These reactions are well recognized. But is a closely related reaction 
well enough recognized? Here is an examination question I proposed several 
years ago. A young, healthy male of 22 comes into the hospital with fever, 
nausea, and vomiting, extreme pain in the lower right quadrant and an elevated 
white count. The physicians diagnose it as acute appendicitis. He is given 
200-400 mg of pentobarbital and taken to the operating room where he is given 
15 mg of morphine. He is then given ether. The operation reveals an acute ap- 
pendix. Because the patient is not completely relaxed, the surgeon orders 
20 mg of succinylcholine. The patient relaxes but he stops breathing. Now, what 
has gone wrong? Is this a so-called "idiosyncratic" reaction as it was con- 
sidered for a long period of time? No, it is an iatrogenic -created situation. 
This patient happens to be one out of 2,800 humans who doesn't have a normal 
amount of pseudocholinesterase, the enzyme needed to destroy succinylcholine. 
The patient cannot metabolize the drug and only if he is kept alive by artificial 
means can he be saved. 

We can't test everybody to see if he has low pseudocholinesterase in 
his serum before we give succinylcholine, but we must be much more cautious 
in administering the drug. People who are known to have reactions and have 
had trouble with such drugs should be watched. 

We have drugs interfering with organ function. For example, if certain 
hallucinogenic drugs like LSD-25, or even plain, ordinary belladonna alkaloids 
are given, patients can go off into psychotic states so bizzare that the indivi- 
dual confuses time and space and appearances. Such confusion or state may 
last for hours and sometimes for days. Sometimes it can have profound ef- 
fects on the personality of the patient after he recovers from the harrowing 
experiences. 

We have drugs that interfere with cardiac rhythm. Antihistamines that 
are sold over the counter can produce tachycardia. Certain drugs that hit the 
vestibular nerve, such as streptomycin, can destroy the vestibular branch. 
Many drugs that hit the fifth nerve can cause parasthesias. We have peculiar 
reactions from neomycin which will cause shock under certain situations. 

There are drug reactions affecting specific sites or tissues. For ex- 
ample, the eye can be affected by most of the anti -Parkinson drugs. Every 



U. S. Navy Medical News Letter, Vol. 44, No. 2 



drug reaction table / /* /* /*//// / <fs / 

y>//yJcs/s/ ///////// / 

drugs / * V* / &/*/ <* / */ */*/ * / / / 


Acetanitid 


X 
























Acelazolarnide 


















X 


X 






Aminopyrine 














* 






X 






Ammosalicyciic acid 


X 




X 






74 






X 


X 


X 




Anesthetics 












~ S" 














Antihistamines 




X 










X 












Antimony salts 


X 
























Antipyrine 


X 


X 






















Arsenicals 


X 


X 


X 




__A__ 




X 




X 


X 


X . 




Aspirin 












X 




51 










Barbiturates 


X 


X 


_JS_ 




X 




* 








X 




belladonna 






X 




















Bromides 




X 






















UarOarsone 






X 




















Chloramphenicol 




X 










X 


X 


X 


X 






Uhlordiazepoxlde 














If 






X 






Chlorothiazide 


















X 


X 






Chlorpropamide 


















X 


X 


X 




Cortilotfopm 










X 


X 














Cortisone 




■ x - "" 1 








X 














Uehydrocholic aCJd 












X 














bigiTafis 




, 






X 
















Digitoxin 


















)( 








Oinitrophenol 






X" 




















Diphenhydramine 












X 














Dipnenylhydantoin 














X 




X 








Dipyrone 














X 












Erythromycin estafate 






















X 




Estradiol 




















X 






Estrogens 


















X 




X 




Folic Acid 












X 














Gamma benzene hexachloride 














X 






* 






Gold salts 


X 


X 


X 








x 




X 


X 


X 




Heparin 










X 
















Hydanfoins 




* 


X 


X 


X 












X 




Hydralazine 










X 










X 






Insulin 










X 
















Iodides 


x ■ 




X 


X 


. „x 


X 














isoniazid 










X 




X 








X 




Ltver extract 










X 
















Meperidine 












_X__^ 


X 












Mephenyjain 














X 






X 






Meprobamate 














X 




X 








Mereupuilne 






















X 




Mercuiiats 


H 




X 


X 


x 


x 








X 






Met heat heline 






■t 




















Methimazole 














_Ji„ 












Monoamine oxidase inhibitors 






















X 




Naphthalene 
















X 










Nitrofurantoin 
















X 










Novobiocin 






















X 




Opium alkaloids 












X 














Penicillin 


X 


X 


X 




X 


X 


X 


X 


..*.. 


;* 


x, 




PhenacemiiJe 














x 




X 


X 


x 


, 


Phenacetin 


X 


X 












X 
























X 








X 




Phenolohthalein 


X 


X 






















Phenothiazines 






X 




-"x 


X 


* 


X 


X 


X 


X 




Phenylbutazone 




X 


X 




¥ ' 




X 




X 


X 


_J4_ 




Pollen extracts 












X 














Potassium perchlorate 




















X 






Procaine 












X 






X 








Procaine amide * 














X 








X 




OujnacrJne 


X 




X 














X 


. X... 




Qu mi dine 


X 








X 






X 


X 








Quinine 


X 




X. 




X 








X 








Ristocetin 














~ X 




X 


* 








X 


X 






X 




X 




























* 


















X 


X 




















X 


X 




X 


X 


K 


X 


X 


V 


X 




Sulfadiazine 












X 


































X 






SuMamethoxypyridazine 


















* 


X 


























X 


















X 
























X 


















X 


X 


X 


X 


X 




X 


X 


X 


X 


ff 


























X 




Tetracycline 


X 


X 






.. * 




x 


X 




X 


















X 
















_X_ 




X 
















x 


















X 




















X 






X 




X 




















X 




























X 




X 


'"*"' 




























*~- 














X 




















X 






X 


























JT 











































U. S. Navy Medical News Letter, Vol. 44, No. 2 9 

physician who is prescribing these -and pharmacists who are responsible for 
dispensing these prescriptions -must think about the possibility of glaucoma. 
Patients must be cautioned to see an ophthalmologist for care if there is the 
slightest indication of any difficulty. We are also using drugs like chloroquine 
which can produce subtle degeneration in the eye. Patients on long continued 
therapy must be checked by an ophthalmologist if serious harm to the eyes is 
to be avoided. 

Most people, when they think of drug reactions, think in terms of al- 
lergy. Ten to 12 percent of all people are allergic to drugs of one kind or 
another. This is serious and we can expect to have iatrogenic disease occur 
in these patients when we have such a high incidence of drug allergy. It should 
be borne in mind, however, that a great number of reactions have nothing to 
do with allergy but are rather the manifestations of pharmacologic activity. 

The table on page 8 presents a number of examples of hypersensitivity 
reactions to many different drugs. These include the following: 

1- Fixed eruptions are localized eruptions in which a patch of skin will develop 
redness, itching, burning and dryness. Barbiturates, thiazide diuretics 
and phenolphthalein are among the common offenders. 

2 - Erythema multiforme is an acute, inflammatory skin disease characterized 
by reddish macules, usually on the neck, face, legs and dorsal surfaces 
of the hands, forearms and feet. Gastric distress and rheumatic pain may 
be initial symptoms. Drugs which may cause this condition include anti- 
histamines, sulfonamides, and certain antibiotics. 

3. Exfoliative dermatitis is one of the most serious types of drug reactions 
and can be incapacitating or even fatal. In this condition the epidermis is 
shed. The entire body may be involved in severe cases. Offenders include 
hydantoin derivatives, phenothiazines and phenylbutazone. 

4. Periarteritis nodosa (or polyarteritis nodosa) is a rather rare disease in- 
volving a characteristic lesion and nodules and hemorrhage along the 
small arteries. It tends to attack the kidneys and may lead to kidney failure 
and death. Iodides, mercurials and thiouracils are examples of drugs 
which may produce this reaction. 

5. Serum sickness is a delayed hypersensitivity reaction which is manifested 
by swollen, painful stiff joints and often fever for ten days or so after ex- 
posure to the drug. Offenders include hydralazine, serums and vaccines. 

6. Some drugs, such as aspirin, anesthetics and sulfo.bromophthalein, may 
produce shock in which the patient suddenly collapses and may die within 
a very short time. 

7. Many drugs have been implicated in the development of granulocytopenia 
(agranulocytosis), an acute febrile disease associated with a marked re- 
duction in the number of granular leukocytes. Included are chloramphenicol, 
sulfonamides, phenylbutazone, phenindione, thiouracils and phenothiazines. 

8. Several commonly used drugs are capable of producing hemolytic anemia , 
in which there is sudden destruction of huge amounts of blood leading to 



10 U.S. Navy Medical News Letter, Vol. 44, No. 2 

jaundice, liver failure and severe anemia. Again, chloramphenicol is a 
villain. Nitrofurantoin, phenothiazines and sulfonamides are also major 

offenders. 
9. Thrombocytopenic purpura isacondition characterized by hemorrhages in 
the skin and mucous membranes, associated with a decrease in the number 
of blood platelets . Quinidine, for example, may produce complete disap- 
pearance of thrombocytes and severe hemorrhage. Tolbutamide, sulfona- 
mide and many other drugs may cause a similar reaction. 

10. Aplastic anemia is a potentially fatal form of anemia resulting from defects 
of the bone marrow and marked by a deficiency of red cells, hemoglobin, 
and granular cells and by a predominance of lymphocytes. Potassium per- 
chlorate, sometimes used in place of prophylthiouracil in the treatment of 
hyperthyroidism, is particularly dangerous in this respect and probably 
will be abandoned. Chloramphenicol is one of the leading causes of aplastic 
anemia. This drug should not be used carelessly, for long periods of time, 
or prophylactically. I never prescribe chloramphenicol unless there is an 
iron-clad reason for doing so. 

11. A common iatrogenic disease is hepatitis . Among the leading offenders are 
the phenothiazines including chlorpromazine and promazine. Some of the 
newer drugs in this category appear to be less toxic to the liver. Other 
compounds known to be hepatotoxic include erythromycin estolate, mono- 
amine oxidase inhibitors, thiazides and triocetyloleandomycin. 

Drug reactions are creating a very serious problem. It is going to become 
worse and in both pharmacy and medicine we are committed deeply to do what 
we can to prevent and ameliorate the situation. How should we go about 
preventing drug reactions? 

First, drugs should be used only when they are definitely essential. 
One should know why he is prescribing a drug and prescribe it for a definite 
purpose which can be defended from every possible angle if anything should 
go wrong. Self-medication can be dangerous, particularly when people can 
buy all kinds of agents at the supermarkets. 

I am worried about the products sold in supermarkets. Individuals get- 
ting drugs there don't have the benefit of an expert pharmacist to point out 
what can go wrong when these products are taken or to advise people to see a 
physician if they have suspicious symptoms. 

Even with simple drugs such as aspirin, dangerous reactions can occur. 
Aspirin is a safe drug when taken wisely and in proper doses but if it is abused, 
it may be toxic. Recently I have asked my patients about their intake of aspi- 
rin and aspirin-containing drugs. I am amazed at how many are taking large 
amounts of aspirin- 10 to 12 tablets are not unusual for some patients— and 
they don't even look to see what the prescribed dosage on the bottle should be. 
They buy them in a food market and do not even consider them drugs. 

We must select the least toxic agents. If a series of homologs shows 
the more potent ones have less toxicity than the older ones, we should shift to 



U.S. Navy Medical News Letter, Vol. 44, No. 2 11 

the newer and less toxic agents as rapidly as possible. We should obtain the 
therapeutic effect we want and stop the drug promptly if we have gained what 
we desire from it. Patients should not be given large amounts of drugs to use 
as they please, to keep in the medicine cabinet, to use weeks or months after 
the original need has long since been relieved or to give to relatives or friends. 
We should avoid multiple ingredient agents for the most part. It is 
very difficult to design multiple ingredient agents that are going to be specific 
to fit the dose to the person's needs at the particular time of illness. There 
are some that do it but most do not. We must have very careful observations 
of the patient on drugs. Any patient who is on almost any drug (see list in the 
drug reaction table) is subject to trouble and the physician must watch these 
patients. The pharmacist can also help by immediately warning the patient 
about possible harm and advising him to check with his physician if all is not 
going well. 

Finally, all reactions should be reported-not only the reactions that 
occur in the hospital but those discovered in the physician's office. Every 
physician should report the reactions he sees to his hospital adverse drug re- 
action committee. This also applies to pharmacists. If somebody develops a 
skin reaction, it is the pharmacist's duty to see that he gets to the physician. 
Patients may get reactions and nobody sees them except the pharmacist. When 
reactions are reported, we can get a better picture of what is going on in this 
new field of medicine. 

NOTE: Dr. Friend, Mr. Griffenhagenandhis staff of the Journal of the Ameri- 
can Pharmaceutical Association are congratulated for publishing this 
article -easily one of the most important contributions to medical lit- 
erature in the past 25 years. It is strongly recommended that the drug 
reaction table be reproduced at all medical care facilities, and that 
MC,DC,MSC, and NC officers be alerted and encouraged to add their 
personal observations to the list-to keep it alive and current. For ex- 
ample, it is known that some drugs will cause a rather rapid develop- 
ment of erythema nodosum, as well as erythema multiforme. Also 
whole blood, fractions of blood, and plasma expanders are so much a 
part of today's therapeutic arsenal that special attention must be paid 
to their dangerous potential. Shortly, there will be distributed from 
BUMED to key treatment activities a monograph on transfusion prob- 
lems. It bears the title General Principles of Blood Tra nsfusion, and 
was prepared by the Subcommittee on Transfusion Problems, National 
Academy of Sciences, Division of Medical Sciences, National Research 
Council. It is published by J. B. Lippincott Company, Philadelphia 
Penna. , and is priced at $1. 50 for single copies - less if order is for 
50 or more copies. 

Lastly, I would like to give credit to CAPT Claude V. Timberlake, 
Jr. , MSC USN of BUMED for his initiative andbroad vision in focusing 



12 U.S. Navy Medical News Letter, Vol. 44, No. 2 

our attention on the unusually great importance of Dr. Friend's article, 

and for his timely action in obtaining approval for its re -publication 

in the Medical News Letter. 

— Editor 

# s|< * $ S}! * 

Testic ular Tumors 

LT M. L. Cowen MC USN* and LCDR R.I.Morgan MC USN**. Proceedings 
of the Monthly Staff Conferences of the U. S. Naval Hospital, NNMC, Bethesda, 
Md. , 1963-1964. 

Testicular tumors in the files of the Pathology Branch, Laboratory Depart- 
ment, were reviewed. One hundred and ninety-three cases were indexed. Path- 
ological material, slides or blocks, was available in 155 of these. Information 
on follow-up of two or more years was obtained on 83 cases. 

Fourteen cases of non-germinal tumors of testis were available for 
study. These included four patients with adenomatoid tumors, all of whom 
were alive two or more years after orchiectomy. Four patients had carcinomas 
metastatic to testis. These four were dead within two years. One patient with 
lymphosarcoma presented first with testicular infiltration by this tumor and 
died of his disease within three years. One patient had an adenocarcinoma of 
the rete testis and he was alive and well ten years after orchiectomy, retro- 
peritoneal lymphadenectomy, and irradiation. The only Negro patient in the 
entire series had a liposarcoma involving the testis but extending into the 
retroperitoneal space. 

Two-year follow-up and pathological material were obtained on 69 pa- 
tients with germinal tumor s. The four elements of germinal tumors, (1) semi- 
noma, (2) embryonal carcinoma, (3) teratoma, and (4) choriocarcinoma, may 
occur in all combinations. It is apparent that a classification including all of 
these as separate entities would be unwieldy and of little value. Dixon and 
Moore have divided these into five groups on the basis of prognosis. Their 
classification is based on two postulates :{1) Though pure seminoma has a re- 
latively good prognosis, when seminoma occurs in combination with one of the 
other germinal cell species, the prognosis of the patient is similar to that of 
a patient with a tumor of the other germinal species with seminoma; (2) The 
prognosis of patients with teratoma plus embryonal or choriocarcinoma is 
better than that of patients with embryonal or choriocarcinoma without tera- 
toma. The following two tables show the two-year (or more) survival rates: 
( 1) in Pure Embryonal Carcinoma compared to Embryonal Carcinoma combined 



* Staff Officer, Pathology Department, U. S. Naval Medical School, NNMC. 
** Formerly Resident in Pathology and Staff Officer, Pathology Department, 
U.S. Naval Medical School, NNMC. Now serving as Staff Officer, Pathology 
Service, USNH, Philadelphia, Penna. 



U.S. Navy Medical News Letter, Vol. 44, No. 2 13 

with Seminoma, and (2) in Embryonal Carcinoma (with or without seminoma) 
compared to Embryonal Carcinoma combined with Teratoma. 

Table I (Survivals) 

Pure Embryonal Carcinoma 4 of 13 (31%) 

Embryonal Carcinoma with Seminoma 3 of 6 (50%) 



Table II (Survivals) 

Embryonal Carcinoma without Teratoma .... 7 of 19 (37%) 
Embryonal Carcinoma with Teratoma 4 of 6 (67%) 

These results appear to agree with the postulates and the authors have there- 
fore used the classification based upon them. The incidence and survival data 
are summarized in Table III: 



Classification 

1. Pure Seminoma 

2. Embryonal with or without Seminoma 

3. Teratoma with or without Seminoma 

4. Teratoma with Embryonal or 
Choriocarcinoma 

5. Choriocarcinoma without Teratoma 

Total with follow-up 

The effect of retroperitoneal node dissection (in addition to orchiectomy and 
irradiation) in Embryonal Carcinoma is summarized in the next table. 

Table IV (Survivals ) 

Embryonal with node dissection 3 of 6 alive 

Embryonal without node dissection 4 of 13 alive 

This appears to indicate that node dissection is of value, but a prospective 
study is necessary to evaluate this therapeutic measure. 

Pathologic material and follow-up data were obtained on 83 cases of 
testicular tumor. The basis of classification was discussed and a summary of 
the incidence and survival of patients with these tumors was presented. 

9(C $ $ $ $ $ 



Table III 








Incidence 


Survival 


inoma 
noma 


29 (42%) 

19 (28%) 

9 (13%) 


23-29 (80%) 
7-19 (37%) 
4-9 (45%) 


oma 


8 (12%) 
4 (5%) 


6-8 (75%) 
0-4 (0%) 




69 


40-69 (58%) 



14 U. S. Navy Medical News Letter, Vol. 44, No. 2 

Surgical Operations on the Unborn Fetus 
May Presage New Era for Immunology Research 

Washington, D. C. , June 18, 1964 (AFIP). Clues to solving problems of trans- 
planting human organs may lie ina dramatically radical series of experiments 
currently being conducted by a research team at the Armed Forces Institute 
of Pathology. Their program has been underway for the past five years. The 
methodology, which involves operations on ovine fetuses (unborn lambs) out- 
side the anesthetized mother's uterus, may shed light on how the adult de- 
velops immunity to infectious diseases and how transplanted organs from one 
human to another are rejected by the recipient. The studies are being con- 
ducted by Dr. A. M. Silverstein, a civilian immunologist, and CAPT K. L. 
Kraner, an Air Force veterinarian, for the Army Medical Research and De- 
velopment Command. 

Basically, the procedure involves completely removing the tiny fetus 
from the mother 's uterus, leaving it attached only by the umbilical cord. While 
out of the uterus, the fetus can be immunized, grafted with tissues from an- 
other animal, or have its thymus removed. (The thymus is considered to play 
a major role in development of immunity in the animal). The fetus is then re- 
placed into the mother's uterus, and at a later date is again removed to allow 
the doctors to study the response of the fetus to antigenic stimulus— what it 
will respond to, when it will respond and to what type of stimulus. The 
researchers are now beginning similar operations on fetal monkeys whose 
characteristics more closely resemble man's. This is expected to provide 
considerable new information on the development of immunity to disease and 
the body's ability to accept foreign tissue. 

The values of the program are at least three-fold in that they: are 
expanding the basic knowledge of the body's responses to immunization 
which could lead to improved immunization processes; might provide better 
approaches to immunization of the newborn to afford more protection against 
infectious diseases to newborn babies; may give clues to the solutions of some 
of the problems in skin and organ transplantation which has obvious potential 
application in military surgery. 

Perhaps the most startling result of the experiment is that the opera- 
tions do not interfere with pregnancy and do not impede the development of the 
fetus. "The amazing thing is that we can do this (remove the fetus from the 
uterus) virtually with impunity, " Dr. Kraner said. "Initially, we doubted the 
fetuses would survive, but they do. We have performed almost 100 operations 
of this type, many of them repeated on the same fetus, with very few failures. 
The development of these animals apparently has not been impaired. " Dr. 
Kraner added that with the umbilical cord intact, the fetus is much hardier 
than suspected. In many cases, the undisturbed twin offers a ready comparison 
in development. Contrary to the earlier belief that an animal cannot develop 
immunity before birth, these studies have shown that the fetal lamb can form 
protective antibodies very early in gestation; its ability to respond to others 
does not develop until some time after birth. 



U.S. Navy Medical News Letter, Vol. 44, No. 2 15 

The fetal lamb is not the only developing animal that can produce an 
immunity in utero. An AFIP study of aborted fetuses has shown that when the 
human fetus develops congenital infectious diseases such as syphilis or toxo- 
plasmosis as a result of maternal infection, it also attempts to protect itself 
by an immune response. Drs. Silverstein and Kraner express the hope that 
clarification of these processes in the fetus may provide clues for improving 
immunization procedures in newborns. 

Another major finding is that immunity to disease is not the only func- 
tion possible in the fetus. The fetus can also reject grafts of tissues and or- 
gans. The scientists have proven that the fetal lamb can reject skin grafts any 
time after the middle of the gestation period. The study of how the fetus re- 
jects a graft in its special intrauterine environment has already clarified some 
of the basic mechanisms involved in the immunologic rejection of foreign 
tissue. 

Techniques for transplanting organs from one human to another have 
been receiving a growing amount of attention both from the medical profession 
and the public in the past few years. This interest, at least on the part of the 
public, has been whetted by occasional and widely publicized successes in 
kidney transplants. These transplants, however, have involved the use of 
immune -suppressive drugs which not only lower the body's natural tendency 
to resist foreign tissue but also its resistance to other foreign substances 
such as a cold virus. There have been equally well-publicized failures. Ideally, 
transplants would be possible without the use of those drugs which lower the 
body's resistance to various diseases. Doctors Kraner and Silverstein are 
trying to find out if and how that would be possible. 

—Adapted from Information Activities Office News Release, Walter Reed 
Army Medical Center. 

% 4 s sJ 1 # ■♦ sfc 

FROM THE NOTE BOOK 



Medical Department Orientation Course 

The Medical Department Correspondence Course "Medical Department Ori- 
entation" NavPers 10943-A-l, is now ready for distribution to eligible regu- 
lar and reserve officer and enlisted personnel of the Armed Forces. Applica- 
tions for this course should be submitted on Form NavPers 992 (with the 
appropriate change in the "To" line), and forwarded via appropriate official 
channels to the Commanding Officer, U. S. Naval Medical School, National 
Naval Medical Center, Bethesda, Maryland 20014. 

This correspondence course is intended for both officer and enlisted 
personnel of the Navy Medical Department. It covers the historical back- 
ground of the Medical Department, the Bureau of Medicine and Surgery, facili- 
ties of the Medical Department ashore, naval medical centers, medical and 



16 U.S. Navy Medical News Letter, Vol. 44, No. 2 

dental facilities afloat, the naval hospital in naval hospital ships, medical 
and dental facilities in advanced bases, medical and dental support of the 
U.S. Marine Corps, and the training program of the Medical Department. 

The course is composed of three (3) objective -type assignments and 
is evaluated at five (5) Naval Reserve promotion and/or non-disability retire- 
ment points. These points are creditable only to personnel eligible to receive 
them under current directives governing retirement and/or promotionof Reserve 
personnel. This is a minor revision and personnel who completed NavPers 
10943 -A will NOT receive additional credit for completing this revision. 
—Submitted by CAPT J. H. Stover, Jr. , Commanding Officer, U. S. Naval 
Medical School, NNMC, Bethesda, Md. 

$ $ $C $C ]£ 2$ 

Naval Medical Research Reports 

U. S. Naval Medical Research Institute, NNMC, Bethesda, Md . 

1. Thermal Protection During Immersion in Cold Water: MR 005. 13-4001. 06 
Report No. 1, March 1964. 

2. Chemical Mechanisms in Oxygen Toxicity: MR 005.14-3001.02 Report 
No. 4, March 1964. 

U. S . Naval Medical Field Research Laboratory, Camp Lejeune, N. C. 

1. The Prediction of Rifle Marksmanship by Performance Tests:MR 005. 01- 
0030 Subtask 2 Report No. 2, May 1964. 

2. Antibodies to Mouse Hepatitis Viruses in Human Sera: MR 005. 09-1204 
Subtask 4 Report No. 14, May 1964. 

U. S. Naval Air Dev elopment Center, Aviation Medical Acceleration Labora - 

tory, Johnsville, Penna. 

1. A Generalized Theory of Particulate Electron Conduction Enzymes Applied 
to Cytochrome Oxidase. A Theory of Coupled Electron and/or Ion Trans- 
port Applied to Pyruvate Carboxylase: MR 005. 13-0002. 7 Report No. 25, 
April 1964. 

U.S. Naval Medical Research Laboratory, U.S. Naval Submarine Base, New 
London, Conn. 

1. Human Factors and the Work Environment.il. The Impact of Isolation upon 
Personnel: MR 005. 14-2100. 03. 07 Report No. 358, July 1961. 

2. Behavioral Energetics. I. A, Factor Analytical Study of Individual Differ- 
ences in Modes of Energy Discharge Resulting from Experimentally- 
Induced Frustration: MR 005. 14-2100-3.07 Report No, 378, March 1962. 

3. Prediction of Adjustment to Prolonged Submergence Aboard a Fleet Ballis- 
tic Missile Submarine. II. Background Variables : MR 005.14-2200-1.04 
Report No. 384, July 1962. 

$ $ ♦ ♦ $ ♦ 



U. S. Navy Medical News Letter, Vol. 44, No. 2 



17 




MISCELLANY 



Advanced Notice of Revised Procedures Concerning 
Examination of Candidates for Service Academies 

By CAPT Herbert H. Eighmy* MC USN - Senior Medical Officer, Severn 
River Naval Command 

1. Candidates for the Armed Forces Service Academies are a very special 
group in many respects, not the least of which is their physical aspect. 
Every ArmedForces Medical officer is in a position to do his country a 
great service or a grave disservice each time he examines and reports 
upon the physical findings of any candidate. It is absolutely essential that 
successful candidates for admission conform to the well established rules 
and regulations concerning physical findings at the time of admission if we 
expect or hope that the product available at the end of four years can meas- 
ure up to standards for commission and thus a reasonable aspect of serving 
as an officer for several years thereafter. 

2. Recently the House Armed Services Committee directed that the Department 
of Defense unify the admission standards (academic, physical aptitude, and 
medical) for all the service academies, insofar as possible. In this regard, 
much attention has been leveled on the concept that since the academies are 
sponsored by the federal government the candidates shouldbe interchange- 
able and all subject to the same physical standards, and yet there are dif- 
ferent demands and limitations on the graduates from each institution. Tri- 
service committees were formed to make recommendations for a single 
examination that would satisfy the requirements of all the service academies. 
It was agreed that: 

a. The standard forms now used by the Armed Services (SFs 88, 89, 603 and 
513, if applicable would suffice for the reports. 

b. Reports of medical examination from any or all services would be 
honored by sister services, subject to final approval by the service con- 
cerned. 

c. A single qualifying (formal) medical examination conducted after 1 July 
each year to a closing date (not yet determined) would suffice for any one 
year. 



Captain Eighmy was promoted to the rank of Rear Admiral on July 1, 1964. 



18 U.S. Navy Medical News Letter, Vol. 44, No. 2 

d. Each service will furnish to the other academies copies of reports of 
qualifying examinations conducted, 

e. Preliminary physical examinations should be discontinued and replaced 
by qualifying examination as in {c). 

f. Examinations will be conducted by a flight surgeon or aviation medical 
examiner in all cases where such examiners are available. At hospitals 
not having a flight surgeon or aviation medical examiner, it is considered 
that an appropriate determination regarding aeronautical adaptability 
will be accomplished by a qualified psychiatrist. 

g. The qualifying examination will be accomplished only at Army, Navy, 
and Air Force Hospitals and certain designated examining facilities. 

h. Color tests should be reported by testing with both FaLant and pseudo- 
isochromatic test plates for all candidates. 

i. ECG required on all candidates. 

j. Audiometry on all candidates. 

k. Muscle balance, depth perception test, near point of accommodation, red 
lens test, and cycloplegic refraction required on all candidates. 

1. Personal History Booklet essential and psychological interview re- 
quired by all services, 
m. Physical aptitude test must be completed and successfully passed by 
all candidates. Although the Army and Air Force require more tests 
than the standard Navy tests, the Navy will adhere to its tests for all 
candidates until procedures are established at the Navy examining 
facilities to conduct the PAT examinations required for the other serv- 
ice academies. 

n. All findings should be accurately reported and the reviewing officer 
should indicate which service(s) the report should be forwarded to, without 
indicating whether or not the candidate is qualified, waiverable, or any 
other decision. 

3. Special items: 

a. Vision should be recorded and if less than 20/20 O. U. , the lens indi- 
cated necessary to fully correct to 20/20. 

b. Pilonidal cysts and sinuses should be fully described as to openings, 
pores, sinuses, discharge, induration, size and whether ever inflamed 
or operated upon. 

c. Blood pressure taken in the sitting position should be recorded and the 
maximum persistent range should not be above 130/84. 

d. EPTE items such as diabetes, asthma, hay fever, enuresis, major in- 
jury, operations or illnesses and periods of unconsciousness should be 

fully described and documented. 

e. Personal History Booklet should be reviewed and comments made onits 
last page by the interviewer. 

f. Reading aloud test should be documented and a note made of lisps, stut- 
tering or stammering if it obtains. 



U.S. Navy Medical News Letter, Vol. 44, No. 2 19 

This trial and transition period is being conducted because all of the serv- 
ice academy medical authorities are making a special effort to conform 
to the idea of a single sufficient physical examination satisfactory to all 
hands, and all hands in the Navy are requested to give it a good serious ef- 
fort to suceed. To this end, Commanding Officers of all examining centers 
are enjoined to appoint a single officer to become intimately acquainted 
with the requirements of the qualifying medical examination for the Naval 
Academy and the other items as listed previously and to assure that each 
candidate for any service academy is properly and completely examined 
and accurately reported on the standard forms. If consultation(s) is held, 
the report should be appended to all copies of the final report. Opinions 
are welcome and necessary many times for final board action at the Naval 
Academy, Air Force Academy and Military Academy levels. No commit- 
ment or opinion should be made to any candidate as to whether or not he 
qualifies for any academy. 

It goes without saying that adequate secretarial help is necessary by record 
office personnel familiar with the forms used and that the results of the 
examination should be accurately and completely recorded and forwarded 
promptly to the proper board at the Naval Academy, the Air Force Acad- 
emy or, in the case of Military Academy applicants, to the Surgeon General 
(Army), Washington, D. C. It is mandatory that an officer personally check 
every item of every form submitted in each case processed while the ap- 
plicant is present. The word "waiverable" has taken on a connotation that 
the condition is acceptable; this is not true unless the candidate has many 
other virtues to offset the defect which would also have to be minor. 
Existing regulations concerning the examination and processing of candi- 
dates for enrollment into the various service academies have been revised 
and are currently being cleared within the Department of Defense. Early 
promulgation is anticipated. 



Federal Hospital Luncheon - An Announcement 

The Federal Hospital Executives Luncheon, sponsored this year by the U. S. 
Public Health Service, will be held on Tuesday, 25 August 1964 at 12 noon, 
at McCormick Place, Chicago, Illinois. Doctor Frank B. Berry, Former 
Assistant Secretary of Defense (Health & Medical) will be the guest speaker. 
The Committee on Federal Medical Services of the American Hospital 
Association arranges for the annual Federal Hospital Executives Luncheon 
and coordinates a Federal Hospital Exhibit at the Annual Meeting of the Asso- 
ciation. The Committee is composed of representatives of the Army, Navy, 
Air Force, Public Health Service, Veterans Administration, and the Bureau 
of the Budget. The Committee advises the Council on Government Relations, 
and acts to enhance coordination between Federal Services hospitals and the 
civilian hospitals throughout the country. 



20 U.S. Navy Medical News Letter, Vol. 44, No. 2 

The price of the tickets for the luncheon is $5. 00 per person. They 
may be obtained from CDR D. D. Moore MSC USN, Code 31A, Ext. 61834, 
Bureau of Medicine and Surgery, Navy Department, Washington, D. C. 20390. 
Checks or money orders should be made payable to the American Hospital 
Association, It is requested that tickets be purchased prior to 15 August 1964. 
—Submitted by CAPT John E. Gorman MC USN, Director of the Professional 
Division, BUMED. 

*4c A rfc sfc Sfc m 

It Can Happen Here* 

Reprinted by permission of The Honorable Durward G. Hall MD, Repre- 
sentative from Missouri (7th District). From the Congressional Record 
110(115)? 12578, June 9, 1964. 

{Mr. Hall asked and was given permission to address the House for 1 minute 
and to revise and extend his remarks. ) 

Mr. Hall. Mr, Speaker, as one of the physicians and surgeons in the 
Congress I feel the typhoid epidemic in Aberdeen, Scotland, must serve as a 
warning that "it can happen here, " at any time and at any place unless we ex- 
ercise continued vigilance against typhoid and the other ancient scourges of 
mankind. In this day of "miracle drugs" and widespread inoculations we are 
in danger of becoming complacent, of feeling that the battle has been won 
against these diseases. But plague, smallpox, typhoid, and yellow fever have 
not been conquered. They are rampant in less developed nations, and only 
dormant in the civilized world. Only constant battle can keep them from erup- 
ting again in the Western World. 

In recent years, we have seen outbreaks of typhoid in Zermatt, Switz- 
erland, and in Aberdeen, epidemics of infectious hepatitis in this country, 
smallpox scares set off by infected travelers returning from abroad. The kill- 
ing of millions of fish in our waterways from water contamination apparently 
by pesticides or industrial wastes has been in the headlines. 

As a physician who has lived through some epidemics in this country 
and who has treated many victims, I can assure you they are very real dangers 
and that I have never felt in the least complacent about them. Indeed, my first 
experience on entering practice in Springfield, Mo. , in 1936 was with scores of 
typhoid patients who had contacted the disease from contaminated lake, mains 
and well-water which had sunk to a very low level due to the great drought of 
the time. Two years before as an intern I helped treat victims of the amoebic 
dysentery epidemic in Chicago. And in New York City in 1947 I saw at first 
hand the mobilization of health resources in a smallpox scare. Now all of 
England is endangered by a typhoid epidemic, and we can take no comfort in 
the ocean that separates us. The disease can travel as far and as fast as a jet 
aircraft. This episode in Scotland must awaken us to the potential hazards of 
the health scourges such as typhoid, and every step must be taken now and in 
the future to minimize the peril. There is at this time no known feasible way 



U.S. Navy Medical News Letter, Vol. 44, No. 2 21 

in which these highly contagious diseases— most stemming from filth and 
contamination — can be wiped out once and for all in all countries. 

Typhoid germs are transmitted in impure water supplies, sewage and 
unpasteurized milk. In the past, most typhoid epidemics were caused in the 
United States by sewage contamination of water and milk supplies. More re- 
cently, the disease usually has been traced to a single carrier, often a food 
handler. Contaminated sewage leaking into the water supply caused the Swiss 
epidemic. Apparently a contaminated food handler touched off the Scot epi- 
demic, or from outside contamination of tins of imported beef— washed in 
river water draining a military camp with known typhoid cases. 

Inoculation with killed typhoid vaccines is of value, especially for 
travelers abroad and for military groups, but it is not foolproof. As the Public 
Health Service states, immunization is no substitute for personal hygiene and 
sanitation. But the broad attack must be on keeping our water supplies unpol- 
luted, and our sewage systems effective. The Senate this year has passed 
legislation that would step up the national effort against polluted waterways. 
This bill is now before the Public Works Committee, and I recommend its 
eventual adoption by the House with one reservation. A provision taking con- 
trol activities away from the U. S. Public Health Service should be dropped. 
The agency most concerned with environmental health hazards on human 
health should continue to be the responsible Federal authority in this field. 
The human health aspect of water pollution cannot be deemphasized. 

I have no intention of being an alarmist in this matter. Plague, small- 
pox, typhoid, and yellow fever have declined almost to the point of extinction 
in this Nation. As a result, there has been an understandable tendency by 
health workers to turn their attention to what seemed to be more pressing 
matters. The Scottish typhoid episode should serve as a red flag to us. Now, 
is the time to look again at what we are doing to hold back these ancient dis- 
eases that still cause countless deaths in other parts of the world. 

One highly commendatory activity now being carried on by the Public 
Health Service is its program to eradicate the yellow fever mosquito in the 
South. Ironically, at the urging of the United States and international health 
agencies, most South and Central American nations have eliminated the mos- 
quito aedes aegypti in areas where it could transmit the disease. They have 
the human carriers but not the mosquito transmitter. We have the mosquito, 
but not the carriers. 

Safety controls over public water supplies, rat control to guard against 
a recurrence of the plague, vaccination against smallpox, including regular 
booster shots for adults, and eradication of the yellow fever mosquito are the 
weapons we have and must continually use to keep these old dangers to man- 
kind at bay. 

We must remember, "it can happen here. " 



* The editor expresses his appreciation to Dr. Hall for permitting the 
publication of his speech in the U. S. Navy Medical News Letter. 



Sjc j{e s}: * % 0/: 



2Z U. S. Navy Medical News Letter, Vol. 44, No. 2 




DENTAL tk^LiiJ SECTION 



Appraisal of the Hazards of Dental Ra.diation 

Robert B. Sloane D D S, NY State Dental J. Vol 30, March 1964. 

With the great wave of concern about the hazards of excessive radiation at a 
cyclic ebb, perhaps we can evaluate its effect on dental radiographic techniques. 
For a dental radiograph to be of value as a diagnostic aid, it should have 
the following minimum qualities : 

1. A discernible difference between the teeth and their supporting structures. 

2. A discernible difference between the enamel, dentin, and carious lesions. 

3. A discernible periodontal membrane, if it is not pathologically absent. 

The author believes that the excessive concern for the protection of the 
patient has resulted in the too general acceptance of techniques that produce 
radiographs of poor diagnostic quality. If the radiograph is not of diagnostic 
value, the patient has been subjected to radiation unnecessarily. 

Three areas that may be affected by exposure to dental radiation are: 

1. The tissue directly exposed to the primary beam. 

2. The body in general. 

3. The gonads. 

It has been stated^-' ^ that the local effect on tissue exposedto a properly 
coned and filtered beam is so minimal that for all practical purposes it can be 
disregarded. Normal cells have a high recovery rate from reasonable expo- 
sure to dental x-rays and therefore the transient effect of radiation on the oral 
tissues is negligible. 

The general body effects of dental radiation are evaluated basically in 
their effect on the hemopoietic and endocrine systems. It is generally accepted 
that both of these systems can be affectedby large prolonged doses of radiation. 
A dental patient, however, can be appropriately shielded from the insignifi- 
cant accumulative effects of small, infrequent, and controlled exposures. 

As for the gonadal effect, Culver states, 2 "In dental x-ray per expo- 
sure, gonadal structures in the male receive . 34 milliroentgens and in the 
female .06 milliroentgens. These figures are minute and transposing them to 
dosages that would be effective for genetic changes, we can arrive at the 
following figures. In the male, it would take approximately 30, 000 exposures 
and in the female, 167,000 exposures. " 

The Jouranl of the American Medical Association ^ substantiates Culver's 
statement in an editorial answer to one of its member's questions in the October 
1957 issue. 



U. S. Navy Medical News Letter, Vol. 44, No. 2 23 

Richards 4 arrived at similar conclusions as to the effect of dental x-ray 
on the gonads. 

Even this minimal hazard can be eliminated by covering the patient, 
from shoulder to knee, with a lead rubber apron having a . 5 mm lead equiva- 
lent. 

It appears that the much feared gonadal effect of dental x-ray has been 
overstated. Therefore, reducing the exposure time by increasing the kilovolt- 
age and milliamperage and accepting films of poor diagnostic value seems to 
be protection of questionable value. 

As a matter of actual fact, thoughthe exposure time is decreased when 
the milliamperage is appropriately increased, the patient still receives the 
same total amount of radiation. The milliamps per second will be the same. 
Raising the kilovoltage decreases the exposure time and changes the character 
of the primary beam. The higher the kilovoltage, the shorter the wavelength 
of the primary beam. The shorter the wave length, the greater the penetra- 
bility and the scatter radiation produced. The lower the kilovoltage, the higher 
the film contrast and the greater the tissue differentiation made possible. It 
has been suggested that the kilovoltage selected should be no higher than nec- 
essary for adequate tissue penetration. 

When dental x-rays are taken, the operator, as well as the patient, 
should be protected. The operator should either maintain an adequate distance 
between himself and the line of the primary beam, or stand behind a 1. 5 mm 
lead shield. The patient can be protected by the use of an appropriate dia- 
phragm to reduce the diameter of the primary beam; by the introduction of 
adequate filtration; and by a shoulder to knee lead- rubber drape. 

The dental film manufacturers can contribute to the reduction in x-ray 
exposure by producing films whose greater speed and inherent response to 
x-ray energy is engineered to provide the contrast necessary for proper tissue 

differentiation. 

It would seem that we, as a profession, have unwittingly adopted tech- 
niques that mirror the general concern about x-ray exposure and accepted 
radiographs of" less than diagnostic value. We have been so concerned with 
sparing our patients unnecessary x-ray exposure that we have accepted standards 
for our diagnostic films that do not meet the basic requirements suggested in 
this paper. 

Like the fable of "The Emperor's Clothes" we have seen nothing but 
the long gray cloth. 

References 

1. Richards, Albert G. : Roentgen-ray Radiation and the Dental Patient, 
J A DA 54: 476-487 April 1957, 

2. Culver, Gordon J. : Radiation Effects, Hazards, and Protection as Re- 
lated to Dentistry, N. Y. State D J 23:189-196 May 1957. 

3. JAMA October 1957. Reprinted in J A DA 55: 722 Nov 1957, 

4. Ibid. Cit. 



24 U.S. Navy Medical News Letter, Vol. 44, No. 2 

Effects of Complete Dentures on Facial Esthetics 

Alexander L. Martone DDS, MSc, Norfolk, Va. J Pros Dentistry 
14(2): 231-255, March - April 1964. 

Prosthodontists deal with a balance sheet primarily composed of losses — loss 
of teeth, alveolar processes, tonicity of musculature, elasticity of skin, as 
well as loss or impairment of functions. Because of this, ithasbeen suggested 
that the beginning of prosthodontic treatment should be an evaluation of the 
total loss incurred by the patient. 

The loss of oral structures primarily affects the appearance of the lower 
part of the face, but the restoration must be in esthetic accord with the upper 
part of the face if the harmony of the entire face is to be achieved. Thus, the 
entire face andthat face in function establish the criteria for the living esthetics. 
It is this total esthetic result which must be of concern to the dentist. 

The degrees and variations of the edentulous appearance are influenced 
by the patient's age, sex, race, general health, inherited characteristics, 
length of time the teeth have been out and the ratio of rate of tissue changes in 
the regions of the lips and cheeks in comparison to the rate of change in other 
regions. If oral support is lost at middle age or in old age, after normal 
growth and development have occurred, and after normal neuromuscular pat- 
terns have been established, facial contours usually change at a slower rate. 
Normal degenerative processes, such as the loss of elasticity of skin, reduction 
of size of fat cells, and loss of elasticity or decrease of connective tissues, 
are decelerated, and impairment of function produces less drastic results be- 
cause there is no interference with normal growth and development. 

We are in need of more objective means of analyzing the role natural 
teeth and supporting structures play in providing the correct amount of support 
for musculature infunction, and determining for the individual patient the degree 
and kind of artificial support which must be supplied to permit the muscula- 
ture to continue to function efficiently. 

The loss of teeth and their supporting structures produces radical 
changes in facial appearance. Successful efforts to restore the appearance of 
the face with complete dentures are dependent upon the knowledges of the anatomy 
of esthetics, and the esthetics of anatomy. The former constitutes a respect 
for the integrity of anatomic demands, whereas the latter is an appreciation 
of the beauty of anatomy as it fulfills these demands. 

In the article the author relates his observations of the effects of tooth 
position and denture base contour to the anatomy and physiology of the facial 
structures and tissues and suggests techniques for the further study of facial 
contour. 

(Submitted by CAPT M. L. Parker DC USN, U.S. Naval Dental Clinic, 
Pearl Harbor, Hawaii) 

fcV J* fcV J* *A- %V 



U. S. Navy Medical News Letter, Vol. 44, No. 2 25 

Hemangiomas of the Mandible and Maxilla 

Bruce A. Lund DDS and David C. Dahlin M D, Mayo Clinic, Rochester, 
Minn. Jour of Oral Surgery Anesthesia and Hospital Dental Service 
22 {3): 234-242 May 1964. 

Hemangiomas, although rarely reported as involving the mandible and maxilla, 
probably occur much more frequently than indicated by surveys of the litera- 
ture. The unsuspected existence of an intraosseous hemangioma can result in 
life endangering postoperative emergency. The simple extraction of a tooth 
having this vascular tumor involving the periapical area is capable of producing 
a spontaneous hemorrhage which is extremely difficult to arrest. 

The authors found in their detailed report of 4casesanda survey of 35 
other cases seen at Mayo clinic that the peak incidence was in the second decade 
of life, although the lesion may be found in any age group. In three of the 35 
cases reviewed the lesions were fatal. Two thirds of the lesions occurred in 
the mandible. Clinically the tumor tends to produce a hard, non-tender swelling 
with a history of having slowly increased in size over a period of months or 
years. Pain is not a constant finding although alteration of nerve sensation has 
been reported. Radiographically, hemangiomas of the mandible or maxilla may 
present a "sunray" appearance with numerous trabeculae radiating in all 
directions within an expansile radiolucent area. A more common finding, how- 
ever, is the "soap bubble" effect produced by multiloculation and resembling 
the radiographic appearance of a giant cell tumor. In other cases ill-defined 
areas of radiolucency have been reported. 

Histologically the tumor may be of the cavernous or capillary type with 
variations in degree of cystic formation and ossification. These tumors although 
benign, have the potential for rapid increase in size becoming locally destructive 
and invasive. Resection, curettage and radiotherapy have been used successfully 
in the treatment of these lesions, with the proper surgical precautions for con- 
trolling hemorrhage. The possibility of the existence of this lesion should be 
considered in making a preoperative diagnosis of any large periapical radio- 
lucency. 

(Submitted by CAPT P. J. Boyne DC USN USS Bon Homme Richard 
CVA-31) 

*N i.! j *j« *J> vP.w vV 

^j 1 * f-jT- vp ^"|* 1* r^ 

Numbness in Chin may Point to Carcinoma 

Numbness of the chin and lower lip may indicate possible malignancy, two 
dentists reported. 

In an abstract of an article, in Dental Abstracts , Drs. JohnR. Calverley 
and Alex M, Mohnac, Lackland AFB, Texas, described clinical findings in 
five patients with metastatic carcinoma. 



26 U. S. Navy Medical News Letter, Vol. 44, No. 2 

In all five cases, a "metastatic malignant lesion in the lower jaw pro- 
duced the numbness. " The primary site in three cases was traced to breast 
carcinoma and in a fourth case to Hodgkin's granuloma. In the fifth case, the 
malignancy had metastasized throughout the body. 

In one of the five cases, numbness of the chin was the first sign of 
malignancy, 

"Of the five patients, none had swelling in the involved region, and 
only two complained of pain in the jaw. All, however, had altered sensation 
in the distribution of the inferior alveolar nerve, " they explained. 

The altered sensations ranged from spotty prickling sensations in the 
jaw to numbness of the entire chin, they stated. 

Drs. Calve rley and Mohnac are stationed at the U.S. Air Force Hospital 
at Lackland AFB. 



Problem of Broken Appointments 

The problem of broken appointments, with the resultant loss of valuable pro- 
fessional time and perhaps an increased waiting time for others seeking ap- 
pointments, is discussed with senior dental officers by the Inspector General, 
Dental, during his surveys throughout the world. Apparently, the solution is 
one of education. That is, pointing out to others during Department Head 
meetings the importance of keeping dental appointments and, at the time of 
appointment, to remind the individual of his obligation to keep his appointment 
or notify the clinic. If appointments are needlessly broken or cancelled too 
late to properly utilize the time, a dental appointment failure notification similar 
to the one described below may be utilized. 

DENTAL DEPARTMENT 
TO I f- Retain in filet 6 months. 



RANK/KATE FILE/SERVICE NO. 



SCHEDULED DENTAL APPOINTMENT (Date 
t limt) 



1. This person failed to keep a scheduled dental appointment. 

2. It is requested that necessary action be taken to ensure that dental appointments 
are kept. Notify this office by endorsement below of action taken. 



DATE 


SIGHED (Denial Officer) 




FIRST ENDORSEMENT 


TO 

Dental Officer 


FROM 



ACTION TAKEN 



U.S. Navy Medical News Letter, Vol. 44, No. 2 27 

Personnel and. Professional Notes 

11 ND Annual Dental Meeting Honors Local Dental Society . The annual Profes- 
sional Military Symposium sponsored by dental officers of the 11ND honoring 
members of the San Diego County Dental Society was held on 15 June 1964, at 
USNTC, San Diego, California. The following table clinics were presented: 

Immediate Occlusal Stent Powdered Gold 

CAPT A. L. Wallace, DC USN David Kaylor, Student 

and LT V. R. Mancuso, DC USNR School of Dentistry 

NDC Camp Pendleton, California Loma Linda University 

Car dio -Pulmonary Resuscitation Silicone Investment Technique 

CDR W. J. Jasper, DC USN for Prosthetic Dentistry 

USNTC San Diego, California James Nethery, Student 

School of Dentistry 
Loma Linda University 

Minor Tooth Movement for the 

General Practitioner 

LT D. L. Turpin DC USNR 

AmPhiBase Coronado, California 

Highlight of the meeting was a presentation by Melvin R. Lund, DMD, 
MS, School of Dentistry, Loma Linda University, entitled, "A New Refractory 
Material - Its Revolutionary Effect Upon a Casting Process. " This material 
is utilized as a die which is handled in a normal manner as it pertains to the 
wax manipulation. It does not use water as a mixing medium but a liquid 
which is supplied. When wax fabrication is complete, the total unit pattern 
and die is invested with the gold being cast direct to the die. The results give, 
what is felt are, prime advantages in that the margins and fit of the resulting 
castings appear consistently better related, as finished restorations, when 
compared to the normal technics. This material has been used to produce 
single castings in excess of a thousand and also many fixed partials, without 
any solder joints. 

12th Annual Tri-service Meeting Held at Camp Zama, Japan . The 12th Annual 
Spring Meeting of the American Stomatological Society of Japan was held 6-8 
May 1964, at Camp Zama, Japan. The membership, comprised of Tri-service 
dentists stationed in Japan, hosted 129 Army, Navy, and Air Force dental of- 
ficers from installations in Japan, Okinawa, Korea, and the Philippine Islands, 
as well as 48 Japanese dentists. 

•fir "it* *>'<* •ff jA* j[j 



28 U. S. Navy Medical News Letter, Vol. 44, No. 2 




OCCUPATIONAL MEDICINE 



Effects of Mild Carbon Monoxide Intoxication 

CDR John H, Schulte MC USN,* Archives of Environmental Health, 
7: 524 -530, Nov 1963. 

Carbon monoxide has been a toxicological problem to man throughout his history. 
The problem began when man encountered his first fire and has continued to 
increase in significance to the present time. Carbon monoxide is currently 
the most important gaseous poison which confronts physicians. It causes more 
deaths than all other toxic gases combined. 

Many studies have been undertaken to determine the earliest changes 
that occur in human subjects exposed to an atmosphere containing carbon 
monoxide. To accomplish this objective, most investigators have attemptedto 
relate the level of carbon monoxide in the blood to the onset of subjective 
symptoms or to alterations in physiological functions. 

The correlation of subjective symptoms with the level of carboxyhemo- 
globin is extremely difficult to evaluate, however. The degree of somatic 
consciousness, responsiveness to suggestion, preconceived ideas and ulterior 
motives of the subject may all play an important part in determining the time 
of onset and the intensity of the symptoms. Furthermore, many authors(2»o» 
11, 12, 14, 16, 17, 19, 20, 23) have found that the symptoms which occur in subjects 
with levels of carboxyhemoglobin below 20 per cent are vague and nondescript, 
and include such subjective complaints as mild frontal headache, vague gen- 
eralized weakness, fatigue, lassitude and drowsiness. These symptoms become 
progressively more severe when the concentration of carbon monoxide in the 
blood increases beyond 25 per cent; and under these circumstances it is reason- 
ably certain that the symptoms which develop are attributable to carbon monoxide. 

Since alterations in physiological activities are influenced to a much 
lesser degree by somatic awareness, suggestibility and preconceptions, the 
correlation of measurable changes in physiological functions to the concentra- 
tion of carboxyhemoglobin is more reliable and accurate than the correlation 
of subjective symptoms to the level of carboxyhemoglobin. Alterations in 
physiological functions are not usually found at levels of carboxyhemoglobin 
below 20 per cent, however. Asmussen and Knudsom 2 ', Haggard(9), and 
other st?' 11' could not find any change in the resting pulse rate, cardiac output 

* Director of Submarine Medicine Division and Special Weapons Defense 
Division, BUMED 



U.S. Navy Medical News Letter, Vol. 44, No. 2 



29 



or blood pressure until the carboxyhemoglobin in their subjects increased to 
a concentration of 20 to 30 per cent. Haldane* 11 ' 12 > did notfindan increase in 
respiratory ventilation until more than 30 per cent of the hemoglobin in the 
blood of his subjects had combined with carbon monoxide. Vollmer, etal. 
could not elicit any measurable disturbances in the visual fields in subjects 
whose blood contained less than 25 per cent carboxyhemoglobin. Table I 
illustrates the correlations found in these studies between the onset of subjective 
symptoms or changes in physiological activities, and the level of carboxyhemo- 
globin. 

Table I 



Signs and Symptoms at Various Concentrations of Carboxyhemoglobin 



% COHb 



Signs and Symptoms 



0-10 No signs or symptoms. 

10-20 Tightness across the forehead, possible slight headache, 
dilation of the cutaneous blood vessels. 

20-30 Headache and throbbing in the temples. 

30-40 Severe headache, weakness, dizziness, dimness of vision, 
nausea, vomiting and collapse. 

40-50 Same as above, greater possibility of collapse, syncope 
and increased pulse and respiratory rates. 

50-60 Syncope, increased respiratory and pulse rates, coma, 

intermittent convulsions, and Cheyne-Stokes respiration. 

60-70 Coma, intermittent convulsions, depressed heart action 
and respiratory rate, and possible death. 

70-80 Weak pulse, slow respirations, respiratory failure and 
death within a few hours, 

80-90 Death in less than an hour. 

90* Death within a few minutes. 



The investigations of the Haldanes< 4 > 10 > n > l2 > 13 > , and others have shown 
that the presence of carbon monoxide in the blood markedly reduces its capacity 
for carrying oxygen. It has been demonstrated further* 1 ' 3 - 5 > 22 > that the 



30 



U. S. Navy Medical News Letter, Vol. 44, No. 2 



functions of the higher centers in the central nervous system are more sensitive 
to a decrease in the level of oxygen in the blood than are the functions of other 
body tissues, including the lower nervous system centers in the pons, cerebellum 
medulla and spinal cord. It can be anticipated, therefore, that the higher nerve 
centers may be more sensitive to the amount of carbon monoxide in the blood 
than are the other body tissues, including the lower nervous system centers. 

Impairment in the functions of the higher nerve centers is frequently 
determined by measuring the degree and type of alteration which can be demon- 
strated in psychological abilities. Fleishman'**' has divided all psychological 
skills or abilities into three large categories — perceptual, psychomotor, and 
cognitive. Each of these categories can be further subdivided into specific 
functions or abilities which are independent of each other. The psychomotor 
skills, for example, have been subdivided into fifteen distinctly different 
functions including such attributes as control precision, multiple limb coordina- 
tion, choice discrimination, reaction time, etc. 

The effects of carbon monoxide have been evaluated for a few of these 
psychological abilities. MacFarland, etal. * 20 ) demonstrated a significant 
degree of impairment in visual discrimination for brightness when the level of 
carboxyhemoglobin in their subjects reached 4 per cent. Lilienthal and 
Fuggitt* ' found an impairment in the frequency of flicker -fusion in subjects 
with levels of carboxyhemoglobin between 5 and 10 per cent. Trouton and 
Eysench* ' have reported the development of impairment in control precision 
and multiple limb coordination in subjects when the concentration of carbox- 
yhemoglobin in their blood exceeded 5 per cent. 

I. Purpose . It was the purpose of this study to determine whether 
alterations in some of the other functions of the higher centers in the central 
nervous system could be demonstrated at levels of carboxyhemoglobin lower 
than those which are necessary to produce subjective symptoms or alterations 
in the physiological functions of other body tissues. Additional aims were to 
determine the minimum level of carboxyhemoglobin at which measurable 
alteration of a function begins, and to correlate the amount of change in each 
function with the increase in the level of carboxyhemoglobin. 

II. Experimental Procedure. Volunteer subjects were obtained for this 
study from the Cincinnati Fire Department. Each volunteer was given a pre- 
liminary interview and a physical examination. The physical examination was 
directedtowardthe elimination of those individuals having any physical defects 
which might interfere with the testing procedures. 

Upon completion of the history and physical examinations, each subject 
was given an explanation of each of the tests to be used. These tests included: 

a) pulse and respiratory rates, and blood pressure 

b) color stimulus response test 

c) letter stimulus response test 

d) carboxyhemoglobin determination using the microgasometrlc 
method of Scholander and Roughton^ ' 

e) plural noun underlining test 



U. S. Navy Medical News Letter, Vol. 44, No. 2 



31 



f) test of neurological reflexes 

g) static steadiness test 
h) arithmetic test 

i) muscle persistent test 

j) t crossing test 

k) time of onset of subjective symptoms. 

The completion of one set of each of these tests constituted one testing 
cycle. The sequence of testing procedures was arranged so that the measure- 
ments of physiological activities were interspersed among the psychological 
tests to eliminate, or minimize as much as possible, the effects of boredom, 
fatigue, and other factors which might otherwise confound the results. Each 
subject was evaluated during four consecutive testing cycles. 

To obtain a wide range of concentrations of carbon monoxide in the blood 
of the subjects during each of the four testing cycles, the subjects were divided 
into one of several groups with respect to exposure to carbon monoxide. Table 2 
shows the schedule of exposure for each of the different groups of subjects. 







Table 2 




■ i i 




Schedule of Exposure to 


Carbon Monoxide 






1st 


2nd 


3rd 


4th 


Group 


Cycle 


Cycle 

air 


Cv^le 
air 


Cvcle 


la 


CO 


air 


lb 


air 


CO 


air 


axr 


Ic 


air 


air 


CO 


air 


Id 


air 


axr 


axr 


CO 


Ha 


CO 


CO 


air 


axr 


lib 


air 


CO 


CO 


axr 


He 


air 


air 


CO 


CO 


Ilia 


CO 


CO 


CO 


air 


Hlb 


air 


CO 


CO 


CO 


IV 


CO 


CO 


CO 


CO 


V 


air 


air 


air 


axr 



The subjects were tested individually in a quiet, well-lighted and well- 
ventilated room. After completing the explanations concerning the study and 
answering any questions, the subject was seated comfortably at the testing 
table and an oxygen mask was adjusted to his face. This mask was fitted with 
an intake and an exhaust valve designed to prevent the subjectfrom re-breathing 
his expired air. The intake valve was connected by means of a large diameter 
flexible rubber hose to a three-way valve positioned so that the investigator 
controlled the subject's breathing medium and could supply air either directly 
from the room's atmosphere or from a gas cylinder without the subject's 
knowledge of his source of air. The gas cylinders used in this study contained 
approximately one hundred parts of carbon monoxide per million parts of air. 



32 U. S. Navy Medical News Letter, Vol. 44, No. 2 

The subject was told that he would wear the mask throughout the entire 
testing period. He was assured that he would not get enough carbon monoxide 
to cause him any physical harm. He was also told that he would not know if 
or when he was breathing the mixture of carbon monoxide and air, since it is 
odorless and tasteless. The simple choice color response and simple choice 
letter response tests were demonstrated and the subject was allowed a pre- 
liminary period of practice performing these tests while breathing room air 
through the oxygen mask. When the subject was completely oriented, the 
testing was begun. 

III. Results . Forty-nine healthy adult males were used as subjects in 
this study. The mean age for the group was thirty-seven and a half years with 
a median age of thirty-nine years. Table 3 shows their age distribution in 
increments of five years. 

Table 3 



Age Distribution of Subjects 



25-29 30-34. 35-39 4-0-44. 45-49 50-55 



Number of 

Subjects 8 9 10 9 10 



The variation in time and amount of exposure to the mixture of carbon 
monoxide and air resulted in levels of carboxyhemoglobin in these subjects 
ranging from to 20.4 per cent. One subject reported that he had developed 
a headache during the testing. His headache began when the level of carbox- 
yhemoglobin in his blood reached 20.4 per cent. The remaining forty-eight 
subjects denied the existence of this or any other subjective symptoms which 
could be attributed to carboxyhemoglobinemia. There was no change in the 
spinal or cranial nerve reflexes in any of the subjects throughout the study. 
Furthermore, there was no impairment in static steadiness at any time. 

The results obtained from the remaining sixteen physiological and 
psychological activities are recorded in Tables 4 and 5*. Table 4 gives the 
number of observations, the mean levels and response, the ranges of response 
and the correlation coefficients between the particular measurement for each 
of these activities and the level of carbon monoxide in the blood. These results 
show that there was no correlation between the level of carboxyhemoglobin in 
the blood and any of the physiological activities which were evaluated. Further- 
more, there was no correlation between the level of carboxyhemoglobin in the 
blood and the reaction time in the simple choice response tests. There was a 
definite, appreciable and statistically significant relationship between the level 
of carboxyhemoglobin in the blood and all other psychological activities with the 
exception of errors in the plural noun underlining. 

Those variables demonstrating a significant correlation between the 
*See pages 34 and 35. 



U. S. Navy Medical News Letter, Vol. 44, No. 2 33 

level of carboxyhemoglobinandthe degree of impairment were analyzed further 
to determine the relationship of age, smoking habits, test interaction and the 
cyclic nature of the testing procedure to the degree of impairment. There was 
no evidence of cyclic effects upon the results of the tests, and there was no 
apparent difference between the test results of the nons moke rs and those of the 
smokers (although the number of nonsmokers was too small to draw statistically 

significant conclusions). 

The measurements obtainedfrom each of these tests were further divided 
into 20 groups by level of carboxyhemoglobin (0 to 0. 4, 0. 5 to 1. 4, 1. 5 to 2. 4, 
etc. , up to 19. 5 to 20. 4 per cent) and the mean and range at each level were 
determined and plotted. Table 5 shows the mean at each level of carboxyhemo- 
globin for these abilities. 

The results indicate that there is a significant increase in the number 
of errors in the letter and color response tests and in the completion time in 
the plural noun underlining test which should be detectable when the level of 
carboxyhemoglobin reaches 3 per cent. 

The results show that both the completion time and the number of errors 
in the arithmetic and in the j^ crossing tests is increased when the level of 
carboxyhemoglobin is increased. This increasing impairment in completion 
time and number of errors should be detectable at levels of carboxyhemoglobin 
between 1 and 2 per cent when an adequate number of subjects is evaluated. 

IV. Discussion. Subjective symptoms did not occur, nor were any phys - 
iological activities affected at levels of carboxyhemoglobin below 20 percent. 
These results are in agreement with those reported by Kiliickt 16 ', Lilienthall 1 "), 
von Oettingen( 21 >, and others ( 6 * l2 ' 22 K 

Psychomotor abilities were sensitive in varying degrees to the presence 
of carbon monoxide in the blood. Reaction time, static steadiness and muscle 
persistence were not measurably altered by concentrations of carboxyhemo- 
globin up to 20 per cent; whereas, choice discrimination clearly indicated 
beginning alteration at levels of carboxyhemoglobin below 5 per cent. 

With the exception of the number of errors in the plural noun underlining 
test, the tests of cognitive abilities were also highly sensitive to the presence 
of carbon monoxide in the blood as shown by a progressive increase inthe 
number of errors and in completion time with increasing levels of carboxyhemo- 
globin. This increase in number of errors and completion time is detectable 
at levels of carboxyhemoglobin below 5 per cent. 

Alteration of function due to exposure to carbon monoxide occurred 
earliest in the higher centers of the central nervous system in that area (or 
areas) of the brain which controls some of the cognitive and psychomotor 
abilities. This alteration can and does occur at much lower levels of carbox- 
yhemoglobin than those which are necessary to produce subjective symptoms 
or alter physiological signs. Furthermore, the degree of alteration in psy- 
chological abilities maybe quite profound before any clinical signs or subjective 
symptoms are elicited. As seen in Table 5 there was a tenfold increase in 
number of errors in choice discrimination when the level of carboxyhemoglobin 
in the blood reached 20 per cent. 



34 U. S. Navy Medical News Letter, Vol. 44, No. 2 

Table 4 
Results of Physiological and Psychological Tests 



Number of 
Test Observations 


Mean (Range) 


Correlation 
Coefficient 


Pulse Rate 


156 


72(55-1 02) /Kin. 


-0.047 


Systolic B.P. 


156 


122(102-1 55) mm Hg 


-0.004 


Diastolic B.P. 


156 


78 (55-90) mm Hg 


-0.025 


Respiratory Rate 


156 


12(9-1 7) /Min. 


-0.020 


Muscle Persistence 








Time, Left Leg 


156 


27(19-4.7) Min. 


0.035 


Muscle Persistence 








Time, Right Leg 


156 


28(19-51) Min. 


0.035 


Letter Responses 


167 


69.6U9-98)/Min. 


0.001 


Color Responses 


167 


71.2(51-99)/Min. 


0.078 


Errors in Letter 
Response 


167 


18.0(0-116) 


0.906* 


Errors in Color 
Response 


167 


18.7(0-115) 


0.847* 


Completion Time PI. 
Noun Underlining 


196 


186.8(87-317) Sec. 


0.81 2* 


Completion Time 
Arithmetic 


196 


835(501-1453) Sec. 


0.665* 


Completion Time 
t Crossing 


196 


123(43-291) Sec. 


0.792* 


Errors in Plural 
Noun Underlining 


196 


17.7(1-46) 


-0.053 


Errors Arithmetic 


196 


4.6(0-12) 


0.590* 


Errors t Crossing 


196 


3.4(0-14) 


0.539* 



* Significant at the 0.001 Level 



U.S. Navy Medical News Letter, Vol. 44, No. 2 35 



Table 5 



Mean of Test Response at Each Carboxyhemoglobln Level 



CQKb% 


Number 
of 
Observations 


Response 
Errors 
Letter Color 


Plural 

Noun 
Time 


Arithmetic 
Time Errors 
(Sec.) 


t Crossing 
Time Errors 
(Sec.) 


00.0 


64 


9.1 


8.4 


166 


778 


3.7 


91 


1.85 


1.0 


2 


7.0 


1.0 


147 


932 


6.3 


91 


2.50 


2.0 


5 


5.6 


7.0 


154 


759 


4.1 


107 


2.33 


3.0 


14 


10.0 


9.8 


178 


790 


5.7 


92 


2.60 


4.0 


4 


10.5 


12.5 


184 


644 


5.0 


81 


3.00 


5.0 


9 


17.3 


19.5 


176 


867 


4.9 


124 


5.69 


6.0 


1 


6,0 


7.0 


170 


776 


4.5 


149 


3.67 


7.0 


12 


20.2 


20.8 


165 


787 


3.6 


109 


2.20 


S.O 


3 


21.0 


25.6 


252 


902 


5.3 


162 


3.60 


9.0 


3 


28.0 


28.6 


202 


840 


2.5 


72 


9.00 


10.0 


8 


22.5 


24.2 


199 


963 


7.4 


144 


4.70 


11.0 


5 


18.2 


21.4 


207 


835 


4.6 


152 


2.83 


13.0 


6 


23.0 


33.3 


216 


1039 


3.2 


107 


3.25 


14.0 


6 


30.0 


32.6 


226 


944 


6.5 


148 


5.50 


15.0 


7 


38.6 


37.9 


237 


1110 


4.3 


158 


3.13 


16.0 


10 


41.2 


41.9 


235 


835 


6.0 


220 


3.75 


17.0 


2 


32.0 


36.0 


222 


— 











13.0 


5 


38.6 


43.2 


244 


1064 


6.2 


233 


6.80 


19.0 


2 











1015 


6.0 


299 


8.00 


20.0 


2 


70.0 


83.5 


208 


— 


— 


___ 






36 U. S. Navy Medical News Letter, Vol. 44, No. 2 

Years of experience have supported the belief that an eight-hour a day 
exposure to the recommended Maximum Allowable Concentration of 100 parts 
per million of carbon monoxide"^' does not adversely affect the health of the 
average worker. The results of this study do not contradict these beliefs; but, 
there are strong indications that levels of carboxyhemoglobin which are physio- 
logically safe can nevertheless produce impairment of psychological skills 
which may be a safety hazard for the worker (rather than a health hazard) and 
may also greatly reduce efficiency and productivity. 

Since the relatively simple cognitive abilities required to perform choice 
discrimination, arithmetic, plural noun underlining, and t crossing tests were 
impaired by low levels of carboxyhemoglobin, it is highly possible that more 
complex psychological functions involving judgments, and situational decisions 
and responses would be greatly affected by exposure to levels of carbon monoxide 
which are sufficient to produce concentrations of carboxyhemoglobin in the 
blood between 5 and 20 per cent. 

Astronauts, airplane pilots, train engineers and many others who must 
make accurate judgments, correct decisions, and rapid responses in the per- 
formance of their duties are exposed to low levels of carbon monoxide in their 
working environment. Is it necessary to lower the maximum allowable con- 
centration of carbon monoxide in their working environment ? Additional studies 
of the effects of carbon monoxide on other psychomotor and cognitive abilities 
including decision making, intelligence, learning, and situational tests are 
definitely indicated. 

V. Summary and Conclusions . The effects of exposures for varying 
lengths of time to an atmosphere containing 100 parts per million of carbon 
monoxide were measured in a group of forty-nine healthy men between twenty-five 
and fifty-five years of age. This exposure produced levels of carboxyhemo- 
globin in the blood of the subjects ranging from to 20. 4 per cent. 

Impairment of function due to exposure to carbon monoxide occurred 
earliest in the higher centers of the central nervous system in that area (or 
areas) of the brain which controls some of the cognitive and psychomotor 
abilities. Impairment is detectable at levels of carboxyhemoglobin below 5 
per cent and the degree of impairment increases with increasing concentration 
of the carboxyhemoglobin in the blood. 

The need for reducing the maximum allowable concentration of carbon 
monoxide in the working environment has been speculated upon. 

Bibliography 

1. Armstrong, H. G. : Principles and Practice of Aviation Medicine 3rded, , 
Baltimore, Williams and Wilkins Co. , 1952, pp. 177-182. 

2. Asmussen, E. and Knudson, E. O. E. : Studies in Acute but Moderate 
CO-Poisoning. Acta Physiol. Scand. 6:67-78, 1943. 

3. Best, C. H. and Taylor, N. B. : The Physiological Basis of Medical Prac- 
tice, 3rd ed. , Baltimore, Williams and Wilkins Co. , 1943, pp. 1303-1342. 



U. S. Navy Medical News Letter, Vol. 44, No. 2 37 

4. Douglas, C. G. , Haldane, J. S. , and Haldane, J. B. S. : The Laws of Com- 
bination of Haemoglobin with Carbon Monoxide and Oxygen. J. Physiol. 
(London) 44: 275-304, 1912. 

5. Drinker, C. K. : Carbon Monoxide Asphyxia. New York, Oxford Univer- 
sity Press, 1938, pp. 276. 

6. Farmer, C. J. and Crittenden, P. J. : A Study of the Carbon Monoxide 
Content of the Blood of Steel Mill Operatives. J. Ind. Hyg. 11:329-341, 
1929. 

7. Filley, G. F. , Macintosh, D. J. , and Wright, G. W. : Carbon Monoxide 
Uptake and Pulmonary Diffusion Capacity in Normal Subjects at Rest and 
During Exercise. J. Clin. Invest. 33:530-539, 1954. 

8. Fleishman, E. A. : Psychomotor Tests in Drug Research. Uhr, L. and 
Miller, J. G. , eds. : Drugs and Behavior. New York, J. Wiley and Sons, 
Inc., I960, pp. 273-296. 

9. Haggard, H. W. : Studies in Carbon Monoxide Asphyxia. I. The Behavior 
of the Heart. Am. J. Physiol. 56:390-403, 1921. 

10. Haldane, J. S. : The Relation of the Action of Carbonic Oxide to Oxygen 
Tension. J. Physiol. (London) 18:201-217, 1895. 

11. Haldane, J. S. : The Action of Carbonic Oxide on Man. J. Physiol. (Lon- 
don) 18:430-441, 1895. 

12. Haldane, J. S. : Respiration. New Haven, Yale University Press, 1922, 
pp. 427. 

13. Haldane, J. B. S. : The Dissociation of Oxyhemoglobin in Human Blood 
During Partial CO-Poisoning. 

14. Heim, J. W. : The Toxicity of Carbon Monoxide at High Altitudes. Jour, 
of Aviation Med. 10:211-215,1939. 

15. Am. Conf. of Governmental Ind. Hygienists: Industrial Limit Values for 
1959. Am. Med. Assoc. Arch. Ind. Health 20: 3, 1959. 

16. Killick, E. M. : Carbon Monoxide Anoxemia. Physiol. Rev. 20:313-344, 
1940. 

17. Krueger, P. D. , Zorn, O. , and Portheine, F. : Probleme Akuter und 
Chronische Kohlenoxyd-Vergiftungen. (Problems of Acute and Chronic 
Carbon Monoxide Poisoning. ) Arch. Gewerbepath. und Gewerbehyg. 
18: 1-21, I960. 

18. Lilienthal, J. L. , Jr. , and Fugitt, C.H. : The Effect of Low Concentra- 
tions of Carboxyhemoglobin on the "Altitude Tolerance" of Man. Am. J. 
Physiol. 145:359-364, 1946. 

19. Lilienthal, J. L. , Jr. : Carbon Monoxide. Pharm. Rev. 2: 3Z4-354, 1950. 

20. MacFarland, R. A., Roughton, F. J. W. , Halperin, M. H. , and Niven, 

J. I. : The Effects of Carbon Monoxide and Altitude on Visual Thresholds. 

J. Aviation Med. 15: 381-394, 1944. 
2 1. Oettingen, W. F. von: Carbon Monoxide - Its Hazards and the Mechanism 

of its Action. U. S. Pub. Health Bull. No. 290, 1944. 
22. Raymond, V. , and Vallaud, A. : L'Oxide de Carbone et 1'Oxycarbonisme. 

(Carbon Monoxide and Carbon Dioxide.) Paris, Institut National de Securite 



38 U.S. Navy Medical News Letter, Vol. 44, No. 2 

pour la Prevention des Accidents du Travail et des Maladies Profession- 
nelles, 1948, pp. 367. 

23. Sievers, R. F. , Edwards, T.I. , Murray, A. L. , and Schrenk, H. H. : 
Effect of Exposure to Known Concentrations of Carbon Monoxide, JAMA 
118: 585-588, 1942. 

24. Scholander, P. F. and Roughton, F.J. W. : A Simple Method of Estimat- 
ing Carbon Monoxide in Blood. J. Ind. Hyg. and Toxicol. 24: 218-221, 
1942. 

25. Trouton, D. and Eysenck, H. J.: The Effects of Drugs on Behaviour. 

Eysenck, H. J. , ed. : Handbook of Abnormal Psychology. New York, 
Basic Books, Inc. , 1961, pp. 634-696. 

26. Vollmer, E.P. , King, B. G, , Birren, J. E. , and Fisher, M. B. : The 
Effects of Carbon Monoxide on Three Types of Performance at Simulated 
Altitudes of 10, 000 and 15, 000 Feet. J. Exp. Psychol. 36: 244-251, 1946. 

£ $ # # % # 




RESERVE ^SBBr SECTION 



Some Plain Talk for Junior Officers 

Reprinted from a letter to Reserve Officers written by RADM John S. 
Lewis, USN— Retired, Executive Director of the Naval Reserve Asso- 
ciation, 1025 Connecticut Ave. , N. W. Washington 6, D. C. Published 
by special permission of the author. 

Young officers who have completed their obligated active duty service, and who 
decide to participate in the Naval Reserve program on inactive duty are generally 
motivated by a desire for one of the following: (1) To continue to enjoy the 
experiences, the way of life and the friendships which they experienced on active 
duty, and by a* patriotic desire to make a continuing contribution to national 
defense. (2) To earn drill pay and active duty for training pay to augment their 
civilian income. (3) To realize retired benefits, including retired payon reach- 
ing age sixty. (4) To avail themselves of educational opportunities which may 
help them in their civilian occupations. (5) To gain increased rank in the Naval 
Reserve — for their own satisfaction and to enhance their prestige and reputation 
among their Naval Reserve associates and in their communities. 

If you are now participating in the Naval Reserve program on inactive 
duty, regardless of your personal motivation, you probably believe that the 
contribution of your time — at the expense of your family, recreational or civic 
activities — will be rewarded by regular promotion and the achievement of 
retired benefits. This could not be farther from the truth! It is important that 
you understand why this is so. 



U. S„ Navy Medical News Letter, Vol. 44, No. 2 39 

When an officer has decided to participate in the Naval Reserve program 
on inactive duty, he immediately has another decision to make — how and where 
to participate. There are a number of factors which influence his decision: 

(1) His geographical location and the types of Naval Reserve units in that area. 

(2) The numbers and types of billets, both pay and nonpay, which may be open 
to him. (3) Family, personal and business commitments which may restrict 
the days of the week or the hours he can attend drills. 

Some particularly fortunate young officers have a choice of units with 
which to affiliate. Some of them elect to acquire minimum promotion potential 
in a personally convenient method. This is not always conducive to promotion, 
particularly in the more senior ranks. Other young officers limit their oppor- 
tunities for affiliation by an unwillingness to take active duty for training, or 
to sign a Ready Reserve Agreement. With reservations of this nature, they 
are laboring under a severe handicap from the very beginning as far as pro- 
motion is concerned. 55% of the officers who have participated in the Naval 
Reserve program for a period of fifteen years, and who have achieved the rank 
of Lieutenant Commander, will not be promoted, and some of them will not 
even become eligible for retired benefits. Unfortunately, promotion to the rank 
of Lieutenant Commander often creates a false sense of security. Many officers 
who have faithfully attended drills, who have taken active duty for training, and 
who have been regularly promoted to the rank of Lieutenant Commander are 
disillusioned, and even bitter, when they thereafter fail of selection to the rank 
of Commander. There are good reasons why they can participate faithfully 
and still reach the end of the road in the rank of Lieutenant Commander. It is 
because they have failed to direct their efforts in the proper channels. In the 
junior ranks participation is the most important factor, but in the senior ranks 
the emphasis is on participation appropriate to your designator. 

Promotion is tangible recognition for participation and performance but 
is necessarily based upon the officer's potential for assuming increased re- 
sponsibility in (a) the next higher rank and (b) in a specific mobilization billet. 
This is no different from the factors that are considered for promotion in 
industry in civilian life. Promotion brings with it increased prestige, higher 
pay and greater retired benefits. Naval Reserve Officers who profess to have 
no interest in promotion are either not being honest with themselves or they 
are wasting their time in the Naval Reserve program. Promotion to the ranks 
above Lieutenant Commander is a highly selective process based upon an 
assessment of the future usefulness of the officer to the Navy and, in case of 
Naval Reserve Officers, it is measured in terms of his potential for service 
on active duty in the event of a national emergency, i.e., mobilization potential. 

Because the Navy had a fixed pattern for your training and duty assign- 
ments from the time of your commissioning until the completion of your obli- 
gated active duty, you may believe that you will receive similar guidance in 
your Naval Reserve activities on inactive duty. This is not so. At the present 
time, and in the foreseeable future, you are to be left largely to your own devices 
as to how and when you participate, what duty assignments you receive, what 



40 



U. S. Navy Medical News Letter, Vol. 44, No. 2 



active duty for training youtake and what correspondence courses you complete. 
Generally speaking, unless you receive experienced and knowledgeable advice 
you will be "flying blind. " Unless you are blessed with an overabundance of 
good luck, it will be just a matter of time before you run aground. The best 
advice you can follow is contained in these five cardinal points: (1) Your 
participation with a Naval Reserve Unit, your active duty for training, and 
your correspondence course activity, must be appropriate to your designator. 
Unless you can obtain a training appropriate to your designator, you should 
request a change of designator. (2) Your promotion essentially depends upon 
high-quality performance as evidenced by your fitness reports, and (3) Your 
record must reflect assignments of increasing responsibility. (4) You must 
have regular periods of active duty for training, preferably in your mobilization 
billet. {5} Your participation must to all intents and purposes, be continuous. 
Where your personal affairs make drill attendance difficult or even impossible 
for a year or two, you must make every effort to continue your professional 
development through correspondence courses and active duty for training. 

When you find you are not meeting all of the foregoing criteria, you 
would do wellto review your personal situation objectively to determine whether 
you can change the pattern of your Naval Reserve activities and whether continued 
participation in the Naval Reserve program is justified. Failure of selection 
to promotion is a sure sign that this review is needed. 

$ $ 9JG 3{C $ $ 



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